L&D

• Premonitoring signs of labor

  • Lightening: uterus sinks downward & forward 2 weeks before term
  • fetus descends into pelvis: pt reports can breathe easier and pee's frequently
  • weight loss and surge of energy
  • water breaks (only 10% of the time)
  • Nesting, backache, Braxton-Hicks Contractions
• True Labor

  • Contractions occur at regular intervals & intervals shorten
  • Contractions increase in duration and intensity
  • Discomfort begins in the back
  • Intensity increases with movement
  • Cervical dilation and effacement are progressive
• Label which column is True labor and which one is False labor

  A) True Labor

  B) False Labor

  
• False Labor

  • Contractions are irregular
  • No changes to cervix contractions
  • discomfort in abdomen
  • movement doesn't effect contraction or it lessens contractions
  • No change in cervical dilation and effacement
• Physiological response to labor

  • Progesterone: causes relaxation of smooth muscle tissue
• Physiological response to labor

  • Estrogen: causes stimulation of uterine muscle contractions
• Physiological response to labor

  Connective tissue loosens and permits softening, thinning, opening of cervix
• Pain Management in Labor

  Continuous support: less likely to need interventions

  Want to empower support person to provide non-pharmacologic support and care at a level they are comfortable with during L&D
• Pain Management in Labor

  • Epidural injection: anesthetic agent into epidural space produces little or no feeling to area from uterus down
• Pain Management in Labor

  • Spinal block: Local anesthetic agent injected directly into spinal canal, level of anesthesia dependent upon level of administration and may be administered higher for cesarean birth
• Pain Management in Labor

  • Pudendal block/local infiltration: Local anesthesia injected into the pudendal nerve, causes anesthesia to lower vagina and perineum, or local infiltration to perineum prior to episiotomy and provides relief only for episiotomy incision

  
• Pain Management in Labor

  • Systemic medications: via IV or inhalation to provide comfort and relaxation
• The 5 P's of Labor

  1. Passenger (fetus and placenta)
  2. Passageway (birth canal)
  3. Power (contractions)
  4. Position of mother
  5. Psychological response (not ready to deliver mentally, won't deliver)
• Effacement: When the cervix softens, thins and shortens. It happens late in pregnancy as your body prepares for labor and delivery. Evaluate during a cervical assessment

  
• Assessment of contractions: uterine contractions assessed by palpation or continuous electric monitoring

  
• Label the 3 phases of uterine contractions of the picture

  A) Increment

  B) Acme

  C) Decrement

  
• Assessment of contractions (frequency, duration, intensity) by palpation

  • Place one hand on uterine fundus
  • keep hand still to not stimulate contractions caused by discomfort
• Assessment of contractions (frequency, duration, intensity) by palpation

  • To determine frequency, note the time from beginning of one contraction to beginning of the next contraction
• Assessment of contractions (frequency, duration, intensity) by palpation

  • To determine duration, note time when tension of fundus is first felt and again as relaxation occurs
• Fetus during labor

  • During labor is a period of stress for the fetus
  • O2 supply (placenta)must be maintained to prevent fetal compromise and promote newborn health
  • Encourage mother to breathe and try not holding breath
• Fetal labor assessments (aim for healthy mom & baby)

  • FHR, fetal position, fetal presentation
  • Normal: FHR- 110 - 160 with no periodic decelerations and moderate baseline variability and accelerations with fetal movement
  • Abnormal: FHR patterns not within normal range, associated with hypoxemia (deficient o2 in arterial blood)
• 7 Cardinal Movements: Label the 7 movements on the picture

  A) Engagement

  B) Descent

  C) Flexion

  D) Internal Rotation

  E) Extension

  F) External Rotation

  G) Expulsion

  
• 1st Stage of Labor (Latent Phase) (best place to be is at home)

  -Cervical Changes and Average Length-

  • Cervix is assessed as dilating 0-3 cm and thinning 0-40%
  • Average Duration: Nullipara 6 hours (first birth), Multipara 4 hours (1+ pregnancies)
• 1st Stage (latent phase)

  -Characteristics-

  • Uterine contractions become established and increase in frequency, duration, and intensity, mild strength
  • Mother may be anxious but is talkative, smiling, eager to talk
• 1st Stage (latent phase)

  -Education-

  • Recommend to labor at home
  • Teach about SROM (spontaneous rupture of membrane), uterine contractions, bloody show, fetal activity
• 1st Stage (transition phase)

  -Cervical Changes and Average Length-

  • Dilate 8-10 cm (fully diltated) and efface 80-100 %
  • Average duration: Nullipara 3 hours, Multipara 1 hour
• 1st Stage (transition phase)

  -Characteristics-

  • Shortest phase of labor
  • More frequent, strong contractions, every 1 - 2 minutes, lasting 60-90 seconds
  • Mother may show significant anxiety and discomfort
• 1st Stage (transition phase)

  -Education-

  • May experience nausea and vomiting
  • Normal to feel loss of control
  • Emotional support -> confident and coaching
• 2nd stage of labor

  • Refers to the time of full dilation to baby birth
  • The 5 P's most influenced this stage (passenger, passageway, power, position, psychological)
  • Episiotomy/ Perineal tears (do you cut or tear)
• Episiotomy: incision made into the perineum to deliver the baby. Can be cut at the medio-lateral or midline

  
• What degree of tear to the perineum is shown in the picture?

  1st Degree

  -Perineum Skin/ lining of vagina

  
• What degree of tear to the perineum is shown in the picture?

  2nd Degree

  • Perineum Skin & Perineum muscles

  
• What degree of tear to the perineum is shown in the picture?

  4th Degree tear

  • Perineum Skin, Perineum muscles, partial/complete disruption to anal sphincter, & lining of anus/rectum

  
• What degree of tear to the perineum is shown in the picture?

  3rd Degree

  • Perineum Skin, Perineum muscles & partial/complete disruption to anal sphincter

  
• 3rd stage of Labor

  • Delivery of the Placenta
  • Occurs 5 minutes after birth (if placenta is not delivered, increase risk of hemorrhage)
  • Characteristics of placenta separation: absence of cord pulse, lengthening of umbilical cord, a sudden gush of blood and a change in shape of the uterus
• 4th stage of Labor

  • Time from 1 - 4 hours after birth
  • Significant physiologic adjustment of the mother's body
  • Nausea, vomiting cease
  • Hemodynamic changes occur (blood loss decreases, less urge to void, need to try and go to bathroom every 20 mins)
  • Bladder hypotonia